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20. Screening for Thyroid Disease

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20. Screening for Thyroid Disease 20. Screening for Thyroid Disease RECOMMENDATION Routine screening for thyroid disease with thyroid function tests is not recommended for asymptomatic children or adults. There is insufficient evidence to recommend for or against screening for thyroid disease with thyroid function tests in high-risk patients, but recommendations may be made on other grounds (see Clinical Intervention). Clinicians should re- main alert to subtle symptoms and signs of thyroid dysfunction when ex- amining such patients. Screening for congenital hypothyroidism is discussed in Chapter 45. Burden of Suffering Hyperthyroidism and hypothyroidism together account for considerable morbidity in the U.S. The total prevalence of these two disorders in ado- lescents and adults is estimated to be 1–4%; prevalence is higher in women and persons with Down syndrome, and increases with increasing age.1–10 The annual incidence in adults has been estimated to be 0.05–0.1% for hy- perthyroidism and 0.08–0.2% for hypothyroidism, with the higher inci- dences cited occurring in elderly women.2,11 In adolescents, an incidence of 0.06%/year for these two disorders has been reported.5 Symptoms of thyroid dysfunction, involving the nervous, cardiovascular, and gastroin- testinal systems, may have an important impact on health and behavior.12 Rarely, fatalities may occur due to thyroid storm in hyperthyroidism and myxedema coma in hypothyroidism.13 Thyroid dysfunction during preg- nancy is associated with an increased risk of adverse maternal and fetal out- comes.14–18 Most patients with thyroid dysfunction will present with typical clinical symptoms and signs within a few months of disease onset, although overt disease may occasionally be overlooked. Studies in which asympto- matic adults of all ages were screened in the clinical setting, often using older, less sensitive tests, detected previously unsuspected thyroid disease in 0.6–0.9% of persons screened.2,3,19,20 The clinical diagnosis of thyroid dysfunction can be more difficult in certain high-prevalence populations, including the elderly, those with Down syndrome, and postpartum women, possibly delaying treatment and risking complications.13 Older persons may experience apathetic hyper- thyroidism, without the goiter, ophthalmopathy, and signs of sympathetic nervous system hyperactivity typically seen in younger persons.21 Typical 209 210 Section I: Screening symptoms and signs of hypothyroidism, like fatigue, constipation, dry skin, and poor concentration, may be confused with symptoms of aging,22 and may also occur less frequently in elderly hypothyroid patients.23 Screening persons 60 years or older in the clinical setting detects previously uns u s- pected hyperthyroidism in 0.1–0.9% and hypothyroidism in 0.7–2.1%.2,19,24–27 The clinical diagnosis of hypothyroidism may also be overlooked in patients with Down syndrome because some symptoms and signs, such as slow speech, thick tongue, and slow mentation, are typical findings of both conditions.6,7 Screening persons with Down syndrome has detected previously unrecognized thyroid disease, primarily hypothy- roidism, in 2.9% (range 0–6.5%).6,7,28 Screening reveals thyroid dysfunc- tion, primarily thyroiditis, in 4–6% of postpartum women.29–32 This dysfunction is sometimes accompanied by nonspecific symptoms, such as fatigue, palpitations, impaired concentration, or depression,31,33,34 that may be mistakenly attributed to the postpartum condition. Women with a personal or family history of thyroid or autoimmune disease, or with thy- roid antibodies, are at increased risk for postpartum thyroid dysfunc- tion.16,30,35–37 Postpartum thyroid dysfunction is usually transient, but it may require short-term treatment to control symptoms. Subclinical thyroid dysfunction as typically defined in the literature is a biochemical abnormality,38 characterized by an abnormal level of thyroid- stimulating hormone (TSH) with otherwise normal thyroid tests and no clinical symptoms. Subclinical hypothyroidism, recognized by an elevated TSH level, is seen in 6–8% of adult women and 3% of adult men.1 As with overt disease, the prevalence is higher in the elderly and in persons with Down syndrome.6,7,24,25,27,28,39–41 Progression to overt hypothyroidism oc- curred in £ 2% of patients who had subclinical hypothyroidism without ev- idence of thyroid autoimmunity or prior thyroid-related disorders and who were followed for 2–15 years; in those with thyroid antibodies, however, progression occurs in about 5–7%/year, and in as many as 20–24%/year in elderly patients with antibodies.25,28,39,42–45 Other than the risk of de- veloping overt hypothyroidism, the importance of subclinical hypothy- roidism is unknown. Case series have suggested adverse effects of an isolated elevated TSH level on blood lipid profile, myocardial function, and neuropsychiatric function,22,46–48 but controlled observational studies have reported conflicting evidence regarding an association between sub- clinical hypothyroidism and any of these adverse effects.49–54 Subclinical hyperthyroidism, recognized by a subnormal TSH level, is seen in 0.2–5% of the elderly population; £ 1%/year progress to overt dis- ease.11,40,55,56 Subnormal levels of TSH are often transient, returning to normal without intervention.3,25,57 There is limited evidence of risk from subclinical hyperthyroidism except when it is due to excessive thyroxine replacement. Case series have reported subclinical hyperthyroidism in a Chapter 20: Thyroid Disease 211 number of patients with atrial fibrillation.58–61 Older controlled observa- tional studies found no association between subclinical hyperthyroidism and atrial fibrillation,62,63 but a significant association was reported in one carefully controlled cohort study that used a sensitive TSH assay.57 One controlled study reported a significantly lower total cholesterol level in pa- tients with a subnormal TSH level,51 suggesting a possible benefit of this condition. Accuracy of Screening Tests Thyroid function tests to detect thyroid disease, including total thyroxine (TT4), free thyroxine (FT4), and TSH, are influenced by a variety of diag- nostic and biologic factors that may affect their accuracy. For example, while TT4 is usually elevated in hyperthyroidism, it misses 5% of cases that 64 are due to triiodothyronine (T3) toxicosis. TT4 concentration is strongly influenced by the concentrations and binding affinities of thyroxine-bind- 38 ing globulin and other thyroid-binding proteins. Falsely abnormal TT4 results often occur with conditions that affect these proteins, such as preg- 38,64 nancy, use of certain drugs, and nonthyroidal illness. FT4 has the ad- vantage over TT4 of being independent of thyroid-binding protein concentrations. Equilibrium dialysis (ED), regarded as the reference method for FT4, is not suitable for routine screening due to its high 38,65 cost. Immunoassay or index (FTI) methods to estimate FT4 are sim- pler, less expensive than ED, and have specificities of 93–99% compared to ED;20,66–68 these methods are not always independent of thyroid-bind- ing protein concentrations, however,38,69 and they may show substantial in- 65 terlaboratory variation. TT4 and FT4 cannot be reliably measured in ill patients, because a substantial proportion will have abnormal thyroid func- tion in the absence of true thyroid disease, due to “sick euthyroid syn- 69–71 drome.” Screening with TT4 or FT4 will generate many false-positive results in healthy populations.2,19,20,71 With test specificities in the mid- 90% range or lower, the low prevalence of previously unsuspected thyroid disease means that the likelihood of disease given an abnormal test will be quite low. In one study, thyroid disease requiring treatment was found in 20 only 13% of those with abnormal FTI results. Because TT4 and FT4 are normal by definition in subclinical thyroid dysfunction, they are not useful as screening tests for this condition. The immunometric (“sensitive”) TSH (sTSH) assays detect low as well as high serum TSH levels, and have become the standard for detecting hy- perthyroidism and hypothyroidism. They therefore offer promise as first- line thyroid screening tests. In unselected populations, sTSH has a sensitivity of 89–95% and specificity of 90–96% for overt thyroid dysfunc- tion, as compared to reference standards incorporating clinical history, ex- 212 Section I: Screening amination, repeat measurement, and/or additional testing including thy- rotropin-releasing hormone tests.3,40,68 In an asymptomatic older popula- tion, the likelihood of thyroid disease given an abnormal sTSH was only 7%, however, reflecting the low prevalence of disease in healthy people.40 Acutely ill patients, pregnant women, and persons using certain drugs such as glucocorticoids may have false-positive sTSH results,38,72,73 al- though specificity is better than for TT4 and FT4 when the three tests have been directly compared.38,74 Newer sTSH assays reduce but do not elimi- nate false-positive diagnoses in such patients.75–77 sTSH may respond slowly to abrupt changes in thyroid function,38 such as those that occur after treatment for hyperthyroidism, but such changes are not generally relevant to the screening of asymptomatic patients. Effectiveness of Early Detection Screening for occult thyroid dysfunction in adults would be valuable if there were clinical benefits of early treatment, including relief of previ- ously unrecognized symptoms. We found no studies evaluating the treat- ment of hyperthyroidism detected by screening
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